Technique for incisional biopsy of a lacrimal gland mass when the diagnosis of benign mixed tumor cannot be excluded clinically

In most cases of a lacrimal gland mass, the management course can be defined clearly based on an accurate history supported by characteristic radiographic features. There are, however, certain cases that do not fit cleanly into management algorithms and, on occasion, it may be necessary to obtain an incisional biopsy into a lacrimal gland mass when the diagnosis of benign mixed tumor cannot be excluded conclusively. We report a technique for incisional lacrimal gland biopsy under these circumstances. To prevent tumor spillage in the event of benign mixed tumor, the incision site into the gland is covered with several drops of butyl-2-cyanoacrylate. The biopsy specimen is submitted for frozen section examination. If the frozen section reveals benign mixed tumor, the entire gland may be removed, with the cyanoacrylate bond protecting the lacrimal gland contents from contaminating the orbit. The technique and its indications are described in detail.     

Adenoid cystic carcinoma of the lacrimal gland: report of a case

Adenoid cystic carcinoma of the lacrimal gland is rarely reported in Japan compared with other countries in Europe and the U.S.A. Here is a report of this rare case. A 26-year-old female had complained of left visual disturbance and left exophthalmos with orbital pain. CT scan and MRI revealed a lacrimal gland tumor in that eye. The tumor was removed via a left frontal craniotomy, and diagnosed as adenoid cystic carcinoma. After operation, she was locally irradiated with a total dose of 5,000 rads using 15 MeV Lineac source. Chemotherapy was started with 5-FU after radiation therapy. An abnormal uptake was observed in the sternum in the bone scintigraphy performed after operation, suggesting metastasis. Visual disturbance improved and exophthalmos and orbital pain disappeared. At the last follow-up at 8 months after operation, she had no signs and symptoms of recurrence or metastasis. Adenoid cystic carcinoma is reported to be the most frequent among the malignant tumors of the lacrimal gland in the Western countries. Prognosis is generally unfavorable with the mortality of 45% to 70%. The 5-year and 10-year survival rate are 45% and 25%, respectively. The mean post-operative survival time is 4.5 years. Since the tumor grows infiltratively into the surrounding tissues, radical excision with total exenteration of the orbit is the treatment of choice. However, it is a difficult decision whether or not to remove the eye with the intact visual function. As for operation, an approach from above through the frontal craniotomy provides a wider operative field and an easier access to the tumor than the lateral approach employed by ophthalmologists.     

A case of metastatic renal tumor originating from a malignant mixed tumor of the submandibular gland]

A rare case of metastatic renal tumor originating from a malignant mixed tumor of the submandibular gland is reported. The patient was a 45-year-old woman with hard masses palpated in the right upper arm and the right upper gluteal region. She had a history of surgical resection of a right submandibular tumor followed by radiotherapy in 1977. Biopsy findings of the gluteal mass suggested a malignant clear cell tumor. A chest X-ray, excretory urogram, CT scan, MRI and renal angiogram were highly suggestive of a right renal cell carcinoma with metastases to the right lung (S1 & S10), the left 4th and 5th ribs, the right upper arm muscle and the right upper gluteal muscle. Right nephrectomy and resection of the right upper arm and right upper gluteal tumors were performed. Microscopic examination showed that all tumors were malignant mixed tumors. When compared to the previous surgical specimen, the tumors were believed to be identical. The tumors of the lung and ribs subsequently resected were malignant mixed tumors. The patient is well with no objective or subjective evidence of recurrent neoplastic disease 7 months post-operatively. To our knowledge only one report of metastatic renal tumor originating from a malignant mixed tumor of the salivary gland has been published in Japan. But metastatic renal tumor originating from the same tumor of the submandibular gland has not been reported previously in Japan.     

Malignant mixed tumor of the lacrimal gland.

This paper reports a case of carcinoma arising in a benign mixed tumor of lacrimal gland following multiple recurrences. The patient had eight recurrences of the benign lesion and after 32 years developed an adenocarcinoma associated with recurrent nodules of still recognizable benign mixed tumor. The literature on malignant mixed tumors of the lacrimal gland is reviewed noting the confusion in diagnostic terminology in early reports. Our patient illustrates the resemblance between malignant mixed tumor (carcinoma arising in pleomorphic adenoma) of lacrimal and salivary gland both clinically and pathologically.     

Hemopneumothorax and hemoperitoneum in a case with large cell carcinoma of the lung.

Hemopneumothorax and hemoperitoneum coincide rarely in nontraumatic cases. Here, a 70-year-old male presented a left axillary lymph node and was diagnosed as having metastatic squamous cell carcinoma. Under the same diagnosis, another lesion developed in the right femur and was resected. One year later, computed tomography detected another tumor in the left adrenal gland. Shortly afterwards, left pneumothorax developed and a chest operation revealed hemopneumothorax due to a ruptured cavitary form of large cell carcinoma. The serum showed a human chorionic gonadotropin-beta level of 1,100 ng/ml. At three-months later, he died of hemoperitoneum. The autopsy demonstrated hepatic metastases and a ruptured adrenal metastasis; microscopy showed marked trophoblastic and squamous cell changes in these organs. This patient was unique in that the rupture of the pulmonary and the adrenal lesions caused clinical manifestation.     

Successful long-term management of hepatic and lymph nodes metastases of ureteral cancer by multimodal treatment including radiofrequency ablation

A 56-year-old man presented with asymptomatic gross hematuria. Computed tomography (CT) scan revealed right hydronephrosis and a slightly enhanced invasive tumor in the right lower ureter, providing a diagnosis of ureteral cancer stage cT3NOM0. The patient underwent minimum incision endoscopic nephrouretectomy, and pathological examination of the resected specimen revealed urothelial carcinoma and squamous cell carcinoma with metastases to right obturator lymph nodes (pT3pN2). Ten months later, CT scan of the abdomen revealed two hepatic metastases. After three courses of combination chemotherapy consisting of gemcitabine and cisplatin (GC), one tumor completely disappeared and another achieved a partial response. The patient underwent radiofrequency ablation (RFA) for the residual followed by GC chemotherapy. However, eighteen months later, CT scan of the abdomen revealed two metastatic foci in other hepatic lesion. The patient underwent RFA again followed by GC chemotherapy and then all hepatic metastases have not revealed enlargement. More than three years after surgery, the patient has achieved a high quality of life.     

Orbital apex leiomyoma with intracranial extension

BACKGROUND: Leiomyoma is a rare, benign smooth muscle tumor of the orbit. It occasionally shows some histologic resemblance to other common tumors of the orbit like neurofibroma and schwannoma. Its location at the orbital apex is uncommon and only one case with intracranial extension has been reported so far. CASE DESCRIPTION: A nine-year-old boy presented to us with left orbital pain. Four years earlier he had undergone partial excision, elsewhere, of a tumor at the orbital apex, which was reported as a schwannoma. The computed tomography (CT) scan showed regrowth of the tumor with intracranial extension. The tumor was totally resected by an intracranial route. One year postoperatively there was no recurrence of the tumor. CONCLUSIONS: Leiomyoma of the orbit, though a benign tumor, does show regrowth after partial excision. Total excision, including any intracranial component, is advised. The cases reported so far are reviewed and the histopathology and possible etiopathogenesis of this tumor are discussed.     

Metastatic renal tumors: clinical report of three cases and review of 136 cases including 38 cases from the Japanese literature

Three cases of metastatic renal tumor are reported. The first case was of a 61-year-old man, who had a Miles' operation for rectal adenocarcinoma 30 months before, and suffered from high fever and right flank pain. Right nephrectomy was carried out and the kidney was found to contain an adenocarcinoma identical to the one previously removed from the rectum. He died 1 year after nephrectomy. The second case was of a 35-year-old man, who had undergone left pneumonectomy for a squamous cell carcinoma of the bronchus. One month later, he was readmitted with cloudiness of consciousness and high fever. Investigations revealed right kidney, adrenal gland and brain malignancies, and which were ectomized totally. On pathological examination all ectomized tissues were metastatic squamous cell carcinoma. He died 1 month after the second operation. The third case was of a 48-year-old man, who had undergone left pneumonectomy for a squamous cell carcinoma of the bronchus. One year after pneumonectomy, abdominal CT showed a left renal tumor. Right nephrectomy was performed and pathological examination revealed a metastatic squamous cell carcinoma. He is now alive 4 months after nephrectomy without any sign of recurrence. A total of 136 cases of metastatic renal tumors including 38 cases from the Japanese literature, are reviewed.     

Recurrent benign mixed tumor of lacrimal gland: report of a case with intracranial extension

A 66-year-old man with benign mixed tumor of the lacrimal gland underwent an excisional biopsy in 1966. Three recurrences subsequently developed, which resulted in an orbital exenteration. In 1979 he came to us. We discovered radiographic evidence and surgical confirmation of recurrent disease involving the lesser wing of the sphenoid and dura in the floor of the anterior cranial fossa. The natural history and management of this tumor is discussed and the relevant literature is reviewed.     

Massive retroperitoneal hemorrhage from adrenal gland metastasis.

We report an unusual case of spontaneous massive retroperitoneal hemorrhage from an adrenal gland metastasis. After medical therapy failed to stabilize the patient's condition, surgical exploration revealed a large retroperitoneal hematoma arising from a right adrenal gland metastasis. At the time of thoracoabdominal exploration in the lower lobe of right lung a small tumor nodule was palpated and resected. Pathologic examination of both lung and abdominal lesions revealed squamous cell carcinoma thought to have been primary in the lung. A review of the literature reveals that metastatic lesions to the adrenal gland are infrequently encountered clinically and rarely hemorrhage; the first such case in which massive retroperitoneal hemorrhage was a complication is reported in the urologic literature.     

A case of carcinosarcoma of the lung]

A 63-year-old man was admitted to our hospital because of cough and slight fever up. A tumor shadow in right S6 and obstructive pneumonia was detected by X-ray and CT. Bronchoscopic study showed that right B6 bronchous was occluded by the tumor and in which malignant cell (squamous cell carcinoma suspect) were detected. Therefore right middle and lower lobectomy was performed. Histological examination of the resected specimen showed that the tumor was composed of poorly differentiated squamous cell carcinoma and abnormal spindle cell component. Both components of the tumor were mixed each other in part. Immunohistologically, malignant cell of sarcomatous elements were positively stained by vimentin and actine, but was not found such as osteosarcoma or rabdomyosarcoma. He was diagnosed as so-called carcinosarcoma of the lung.     

Secondary and metastatic tumors of the orbit

We have presented three cases of metastatic tumor to the orbit. The first case illustrated metastatic tumor that originated from a cutaneous basosquamous cell carcinoma. This lesion, first reported by MacCormac as being morphologically intermediate between basal and squamous cell carcinoma, has become a topic of some controversy. Conley reported these tumors to represent 1% of basal cell carcinomas. Several authors have reported a higher incidence of recurrence with these lesions, as compared with the ordinary basal cell tumors. Recurrence of basal cell carcinomas are reported as approximately 10%, but are four times greater in the basosquamous cell tumors. The incidence of metastasis with the basosquamous cell tumors has been reported in between 37% and 51% of cases. The second case represented involvement of the orbit by direct extension of a facial squamous cell carcinoma. As illustrated by this case, these tumors can be very aggressive and should be treated with respect. The third case showed the metastatic potential of the nephroblastoma with metastatic tumor that involved the eye, orbit, and maxilla. Diagnostic techniques available in evaluation of these tumors include CT scan, magnetic resonance (MR) imaging, ultrasound, open biopsy, and fine-needle aspiration. Li et al., in an article that compared MR imaging, CT scan, and ultrasound concluded that MR imaging, with the use of the 0.15 T resistive magnet, offered no distinct advantage over the combination of CT and ultrasound in evaluation of patients with orbital tumors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Metastatic small cell carcinoma to the pineal body: case report

A case of metastatic small cell carcinoma to the pineal body is reported and the clinical and radiological features of this rare tumor are discussed. A 66-year-old man presented with progressive dementia, gait disturbance, vertical gaze palsy, and convergence retraction nystagmus. Computed tomographic scan revealed a 2 X 3-cm high-density mass in the pineal region, which showed strong contrast enhancement. The tumor was resected through a right occipital transtentorial approach. The pathological diagnosis of the surgical specimens was small cell carcinoma. A systemic workup for the primary lesion subsequently revealed small cell carcinoma of the lung. Although occurring rarely, metastatic tumor should be considered in the differential diagnosis of pineal tumor in elderly patients.     

A case of granulocytic sarcoma (chloroma) preceding acute leukemia

A 2-year-old boy developed proptosis of the right eye in May 1982. He was admitted to Isawa Hospital on June 9. Physical examination revealed a well developed child with slight proptosis of the right eye and swelling of the right temple. Routine serologic and blood examination revealed no abnormality except LDH, ALP and LAP. CT scan showed high density area in the anterior part of the right temporal lobe and lateral wall of the right orbit. He underwent open-biopsy of this tumor on July 15. Eosinophilic granuloma was suspected, but definite diagnosis was not made. Second biopsy was performed at right upper gingiva on August 2. Follow-up CT scan revealed tumor invaded sphenoidal and maxillary sinus. The patient was transferred to Tohoku University Hospital on August 13. On admission myeloblasts appeared in peripheral blood, and bone marrow examination revealed acute myelo-monocytic leukemia. We discussed its difficulty of differential diagnosis in literature.     

Adrenal myelolipoma: a case report

A 51-year old obese man had been followed up for diabetes mellitus and hypertension. Hepatomegaly was noted on routine examination without any complaints in 1981. Through further investigation of the liver, a large hyperechoic mass lesion was shown between right kidney and the liver on ultrasonogram. On admission, diabetes was controlled by diet alone and blood pressure was 160/90 mmHg. without medication. There were no abnormal findings in laboratory data including hormone assays. The mass showed fat density on CT scan and hypovascularity on angiogram. The mass was diagnosed as benign non-functioning right adrenal tumor, most likely myelolipoma. By operation, the tumor was removed through long subcostal incision. The tumor was well defined and encapsulated, 14 X 8 X 8cm. in size and 480g. in weight. Microscopically the tumor was typical myelolipoma with a mixture of hematopoietic and adipose tissue. Postoperative course was uneventful and the patient discharged on 17-th postoperative day. Myelolipoma of the adrenal gland is a rare non-functioning benign tumor consisting of fat cell and bone marrow element. Only 30 resected cases of adrenal myelolipoma have been reported in the world including 7 cases in our country.     

A case of urothelial carcinoma associated with penile metastasis

A 71-year-old man, who had been treated with continuous ambulatory peritoneal dialysis due to chronic renal failure for 5 months, visited our hospital with a complaint of penile induration in April, 1998. He underwent wedge biopsy of the penis. On the day after the biopsy, he had an episode of gross hematuria. Cystoscopy revealed a papillary tumor that seemed to have arisen from the right ureteral orifice and another in the trigone. Computed tomographic scan revealed the bladder tumors and swelling of the internal iliac lymph nodes. The bladder tumors were resected transurethrally. The pathological diagnosis of the specimen from the penile induration was metastatic transitional cell carcinoma.     

Multiple cavernous hemangiomas of the orbits

Intraocular tumors were detected in both orbits simultaneously by computed tomography scanning in a 45-year-old woman complaining of proptosis of the right eye, decreased visual acuity, and diplopia. The tumor in the right orbit was resected by the subfrontal extradural approach, and that in the left orbit by the Kr?nlein-Berke method. The right tumor was found on the side of the external ear of the muscle cone and the left tumor was located inferiorly on the side of the external ear of the muscle cone. Both tumors were cavernous hemangiomas with identical macroscopic and histologic features.     

Squamous carcinoma metastatic to the sternum

A 63-year-old man had a 10 x 16-cm sternal mass 18 months after a second aortocoronary bypass operation. The resected lesion was a metastatic tumor of squamous histology. No primary tumor was found. The diagnostic work-up and treatment options are presented.     

Metastasizing mixed tumor of the parotid: initial presentation as a solitary kidney tumor and ultimate carcinomatous transformation at the primary site

Benign mixed tumors of the salivary glands are generally regarded as indolent and harmless neoplasms. A subset of benign mixed tumors, however, can undergo carcinomatous transformation (that is, carcinoma ex-mixed tumor). Even more rarely, a mixed tumor that is seemingly benign at the microscopic level will metastasize like a true carcinoma (that is, metastasizing mixed tumor [MZMT]). Despite the benign appearance of the metastatic implants, there is usually little doubt regarding their true nature and origin. Patients invariably have had a mixed tumor removed from the parotid or some other salivary gland, and metastatic spread is usually preceded by multiple episodes of local tumor recurrence. We report a case of MZMT that presented as a solitary kidney mass. In the absence of a previous or concurrent salivary gland tumor, its metastatic nature was not appreciated and it was regarded as an unusual but benign kidney adenoma. One year after removal of the kidney mass, the patient presented with signs and symptoms of an aggressive parotid tumor. Pathologic examination of the tumor in the parotid demonstrated a high-grade carcinoma arising from a mixed tumor. This case underscores the importance of considering MZMT when a seemingly benign mixed tumor is encountered at a nonsalivary site, even in patients without a supportive history. Failure to do so may cause an unnecessary delay in primary tumor diagnosis and management, allow the primary tumor to progress toward a more malignant phenotype, and deny the patient a high expectation for a complete cure.     

Mucoepidermoid carcinoma of the conjunctiva: report of a case in a 36-year-old with paranasal sinus invasion

Mucoepidermoid carcinoma is a rare, highly invasive tumor of the conjunctiva that occurs in elderly persons. Although clinically indistinguishable from squamous cell carcinoma, mucoepidermoid carcinoma is more likely to recur following excision and to invade the eye. The following case report describes a 36-year-old man with mucoepidermoid carcinoma of the right caruncle that invaded orbit, paranasal sinuses, and nasal cavity. The patient is the youngest person known to have had this tumor, and represents the first reported case in which mucoepidermoid carcinoma of the conjunctiva has extended beyond the orbit. This case emphasizes the importance of prompt and adequate primary treatment.